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VIChome2026-01-08

Finding into death of L L

34y · Female·Combined drug toxicity (gabapentin, oxycodone, tramadol, diazepam, citalopram, d…

A 34-year-old woman with complex medical history including chronic pain, sleep disorder, anxiety and PTSD died from combined drug toxicity involving gabapentin, oxycodone, tramadol, diazepam, citalopram, desmethylvenlafa…

general practicerespiratory medicinesystemcommunicationgabapentin
NSWhome2025-12-17

Inquest into the death of MQ

55y · Female·acute necrotising bronchopneumonia

MQ, 55, died of acute necrotising bronchopneumonia on 2-3 March 2023. She had developed community-acquired pneumonia from 21 February 2023, presenting initially with referred shoulder pain (later recognised as diaphragma…

general practiceemergency medicinediagnosticdelay
VIChospital2025-12-08

Finding into death of Philip Riley

60y · Male·Aspiration pneumonia complicating Down syndrome

Philip Riley, a 60-year-old man with Down syndrome, Alzheimer's disease, epilepsy, bronchiectasis, and dysphagia, died from aspiration pneumonia at Royal Melbourne Hospital. He had a documented history of recurrent chest…

respiratory medicinepalliative care
VIChospital2025-12-01

Finding into death of Larelle Sheridan Dean

51y · Female·Multiorgan failure in the setting of WHO Class III obesity, chronic excessive al…

A 51-year-old woman with WHO Class III obesity, chronic alcohol consumption, and anaemia died of multiorgan failure following admission with community-acquired pneumonia and respiratory failure. She presented with abdomi…

general medicineemergency medicinehydromorphone
VIChospital2025-11-18

Finding into death of David William James Hearn

57y · Male·Aspiration pneumonia in a man with cerebral palsy, intellectual disability and L…

A 57-year-old man with cerebral palsy, intellectual disability, and Lennox-Gastaut syndrome died from aspiration pneumonia following a short hospital admission. He had a history of recurrent aspiration pneumonia and was …

respiratory medicineemergency medicineantibiotics
NSWhospital2025-11-17

Inquest into the death of Brooke Tiddy

32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…

A 32-year-old woman with Sponastrime Dysplasia (a rare genetic bone disorder) died during elective bariatric surgery. She had undiagnosed subglottic stenosis (airway narrowing) and tracheobronchomalacia. Critical clinica…

bariatric surgeryanaesthesiadiagnosticcommunicationsevoflurane
SAhospital2025-11-14

Coroner's Finding: Wallace, Peter John

67y · Male·hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and …

Peter John Wallace, aged 67, died in custody at Lyell McEwin Hospital from hypoxic respiratory failure complicating pneumonia, pulmonary embolism, and advanced hepatocellular carcinoma. He had been imprisoned at Yatala L…

hepatologyoncologyenoxaparin
SAhospital2025-11-05

Coroner's Finding: Jackson, Dennis Charles

67y · Male·Type 2 respiratory failure due to pneumonia

Dennis Jackson, a 67-year-old from Broken Hill, underwent left upper lobe lobectomy based on a falsely positive lung biopsy contaminated with squamous cell carcinoma tissue from another patient during processing at SA Pa…

cardiothoracic surgerypathologydiagnosticsystem
QLDhospital2025-10-23

Inquest into the death of Shirley Elizabeth Haggett

78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…

78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…

anaesthesiaplastic and reconstructive surgerysystemdiagnosticmidazolam
VIChospital2025-10-13

Finding into death of David Greville Edward Horne

47y · Male·Unascertained; most likely cardiac arrhythmia possibly triggered by obstructive …

David Horne, a 47-year-old man with bipolar disorder, schizoaffective disorder, and severe obstructive sleep apnoea, died suddenly at Maroondah Hospital while under compulsory psychiatric treatment. He experienced two ep…

psychiatryrespiratory medicinediazepam
VICaged care2025-10-10

Finding into death of Christopher Kuric

52y · Male·Aspiration pneumonia in a man with end stage Huntington's disease

Christopher Kuric, a 52-year-old man with end-stage Huntington's disease residing in specialist residential care, died of aspiration pneumonia. He had documented swallowing difficulties managed by speech pathology and di…

neurologypalliative carepossibly_preventabledelay
VIChospital2025-10-09

Finding into death of Christopher Francis O'Riley

57y · Male·Aspiration pneumonia complicating locally advanced non-small cell carcinoma of l…

Christopher O'Riley, age 57, a specialist disability accommodation resident with complex medical needs including lung cancer, schizophrenia, epilepsy, and dysphagia, died from aspiration pneumonia complicating locally ad…

palliative careoncology
VICcommunity2025-09-17

Finding into death of Manpreet Kaur

24y · Female·Pulmonary and miliary tuberculosis

Manpreet Kaur, a 24-year-old Indian national on a student visa, died of pulmonary and miliary tuberculosis on 20 June 2024 at Melbourne Airport. She had been symptomatic for months, presenting to a GP on 19 May 2024 with…

general practicerespiratory medicinediagnosticsystem
VIChospital2025-08-29

Finding into death of John Mark Robinson

61y · Male·Aspiration pneumonia in a man with cerebral palsy

John Mark Robinson, 61, died from aspiration pneumonia complicated by cerebral palsy. He presented to hospital on 29 March 2024, initially had end-of-life care initiated, then improved and was being discharged home. He s…

general medicinerespiratory medicine
NSWhospital2025-08-22

Inquest into the death of Frank Valentine

83y · Male·Congestive cardiac failure due to ischaemic and valvular heart disease, with her…

Frank Valentine, an 83-year-old man, died from congestive cardiac failure due to ischaemic and valvular heart disease, with hereditary haemorrhagic telangiectasia (HHT) and anaemia as contributory conditions. He was serv…

cardiologygastroenterologywarfarin
VIChospital2025-08-22

Finding into death of Melanie Ranken

33y · Female·Respiratory sepsis in a woman with an acquired brain injury

Melanie Ranken, a 33-year-old woman with acquired brain injury from a 2017 motor vehicle accident and post-traumatic epilepsy, died from respiratory sepsis secondary to community-acquired pneumonia. She was admitted to B…

respiratory medicineinfectious diseases
VIChospital2025-08-20

Finding into death of Christine Klofa

47y · Female·Mycoplasma pneumonia secondary to rhinovirus infection

Christine Klofa, a 47-year-old woman with Down syndrome and multiple comorbidities, died from mycoplasma pneumonia secondary to rhinovirus infection. She presented to her GP on 6 June with upper respiratory symptoms and …

general practiceemergency medicineamoxicillin
VIChospital2025-08-20

Finding into death of Arnold Polis

68y · Male·Community acquired chest infection secondary to C6 quadriplegia secondary to rem…

Arnold Polis, a 68-year-old man with C6 quadriplegia from a 1972 diving accident, died from community-acquired chest infection complicated by heart failure. He had recurrent respiratory and urinary tract infections relat…

general medicinepalliative care
VIChospital2025-08-17

Finding into death of Stephen Feltscheer

61y · Male·aspiration pneumonia in a man with Down syndrome and early onset dementia

Stephen Feltscheer, a 61-year-old man with Down syndrome and early onset dementia living in Specialist Disability Accommodation, died from aspiration pneumonia. He was admitted to hospital on 25 July 2024 with a two-day …

palliative careinfectious diseasesmidazolam
VIChospital2025-08-15

Finding into death of Person E

70y · Male·organising diffuse alveolar damage in the setting of hypertensive heart disease,…

A 70-year-old man died in prison custody from organising diffuse alveolar damage in the setting of pre-existing hypertensive heart disease, right ventricular hypertrophy, coronary artery atherosclerosis, and COPD. He pre…

respiratory medicineintensive care

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